Release of Medical Information

Please select one of the following:

I am requesting records to be released from a prior physician to Southwest Children's Clinic I am requesting records to be released from Southwest Children's Clinic to a different office

Please provide the information of whom we are requesting from or releasing to:

Name (Physician, Clinic, Hospital or parent):

Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

I hereby authorize the release of the following records:

Problem List

Immunization Record

Growth Chart

Medication List

Reviewed by MD

Scanned/Logged

Other:

Patient's First Name:

Patient's Last Name:

Date of Birth:

Patient's First Name:

Patient's Last Name:

Date of Birth:

Patient's First Name:

Patient's Last Name:

Date of Birth:

Patient's First Name:

Patient's Last Name:

Date of Birth:

I hereby authorize the release of the above-mentioned medical records and will not hold the releasing party responsible for any legal liability that may arise as a result of the release of this information.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of parent or authorizing party:

First Name of Parent or Authorizing Party:

Last Name of Parent or Authorizing Party:

Date:

Witness' First Name:

Witness' Last Name:

Date

Your information will be encrypted.